An exciting opportunity for a band 4 Integrated Care Co-Ordinator has arisen in the Haverhill Integrated Health Team. The team works collaboratively within a wide range of other health professionals and agencies including Adult Social Care and GP practices. The successful applicant will join a dynamic, friendly team of community nurses and therapists who contribute to an evolving Neighbourhood Health Service.
You will be using a wide range of skills that will require you to be confident and possess effective communication abilities with proficient organisational and coordination skills.
The post holder will be part of a virtual and face-to-face team of health and social care staff . As a n Integrated Care Co-Ordinator , you will provide data, co-ordination, support to clinicians and administrative support to multi-disciplinary teams of health and social services; this is within a defined locality in order to improve joint working practices leading to more effective patient care. As part of this role, you will take on the administrative management of co - ordinating the care and multidisciplinary home visits for an enhanced community support offer.
The post holder will help facilitate the integration of health and social care by maintaining up to date recording systems for organisations and by providing information to any member of the multi-disciplinary team in order to ease processes and communication in agreement with data protection protocol . To work with multi-disciplinary databases and co-ordinate the information generated to inform users and commissioners about interventions and outcomes of the integrated care service.
You will also be required to contribute to the coordination of the multi-disciplinary organisation as well as the delivery of health and social care plans for people who are newly discharged from hospital, discharged from a community assessment bed or who need support within their current home to prevent unnecessary admission .
#BeKnown at West Suffolk NHS Foundation Trust. By us. By our patients. By our community
We are a busy, friendly, rural NHS Trust providing high-quality care and compassion to more than a quarter of a million people across west Suffolk. We care for, treat and support people in hospital, at home and in various community settings.
The West Suffolk Hospital in Bury St Edmunds provides acute and secondary care services (emergency department, maternity and neonatal services, day surgery unit, eye treatment centre, Macmillan unit and children's ward). It has 500+ beds and is a partner teaching hospital of the University of Cambridge.
Adult and paediatric community services, provided in collaboration with West Suffolk Alliance partners, include a range of nursing, therapy, specialist, and ongoing temporary care and rehabilitation, some at our Newmarket Community Hospital.
We do our utmost to achieve outstanding clinical outcomes for patients and our values of fairness, inclusivity, respect, safety and team work guide how we work and behave as a team.
With nearly 5,000 staff, from all over the world, we strive to make our organisation a great place to work. Whatever your role or ambition, we want to help you be the best you can be.
We promote a diverse and inclusive community where everyones voice counts and you can #BeKnown for whoever you are.
Join us. What will you #BeKnown for?
1. Communication:
Act as a central point of contact for health and social care professionals within the Integrated Neighbourhood Team (INT).
Communicate effectively with GPs, acute hospital staff, Social Services, community teams, allied health professionals, voluntary organisations, patients, carers and families.
Exchange factual and sensitive information professionally, maintaining confidentiality at all times.
Facilitate and support multidisciplinary team (MDT) meetings by preparing agendas, circulating documentation, recording minutes and monitoring actions.
Liaise with acute hospitals to support admission avoidance and timely discharge planning.
Communicate service capacity information and operational updates to stakeholders across multiple organisations.
Provide information, guidance and signposting to patients, carers and professionals regarding available services and support pathways.
Escalate concerns relating to safeguarding, deterioration in patient condition, telehealth alerts or other risks in accordance with organisational procedures.
Maintain clear and effective communication through telephone, email, digital systems and face-to-face interactions.
2. Analytical and judgemental:
Collect, analyse and interpret service activity data from multiple systems.
Maintain spreadsheets and databases and produce reports to support service monitoring, evaluation and commissioning requirements.
Monitor hospital admissions, discharges and service utilisation, identifying trends and communicating relevant information to MDT members.
Use established criteria to identify referrals, pathways and patient cohorts requiring intervention.
Exercise judgement when managing enquiries and determining the appropriate service , professional or agency for referral or escalation.
Support the analysis of telehealth activity and outcomes to inform service improvement and planning.
Produce data reports and summaries for presentation at multidisciplinary meetings.
3. Planning and organisational Skills:
Coordinate multidisciplinary care arrangements and community support interventions for patients receiving enhanced care services.
Organise MDT meetings, case reviews, home visit schedules and associated administrative processes.
Manage referrals and coordinate patient pathways across multiple organisations and services.
Prioritise and manage a complex workload independently, responding to changing service demands and competing priorities.
Support the planning and coordination of admissions to and discharges from enhanced care services.
Ensure appropriate services , equipment and support are available at the right time to facilitate safe patient care.
Work flexibly across acute and community settings to meet service requirements.
Coordinate telehealth installations, removals and support activities where required .
4. Clinical Dutie s:
Provide non-clinical coordination support to patients receiving integrated health and social care services.
Support the delivery of agreed care plans through effective coordination of services and professionals.
Facilitate multidisciplinary involvement in patients' care and treatment pathways.
Coordinate home visits and community interventions as directed by clinical teams.
Support the delivery of prescribed equipment and medication under clinician direction.
Contribute to admission avoidance and early supported discharge initiatives through effective care coordination.
Provide patients and carers with information about services and support available within the community.
5. Governance:
Adhere to Trust policies, procedures, information governance requirements and data protection legislation.
Ensure accurate and timely recording of information across all relevant systems.
Contribute to the integration of health and social care services through standardised processes and effective information sharing.
Support compliance with safeguarding, confidentiality and risk management policies.
Participate in service monitoring and evaluation processes through the production of activity and outcome reports.
Escalate incidents, risks and governance concerns in accordance with Trust procedures.
Contribute to quality improvement initiatives aimed at reducing duplication and improving integrated working.
6. Finance and Resources:
Order equipment and resources required to support patient care and service delivery.
Coordinate the distribution and retrieval of telehealth equipment.
Maintain accurate records relating to equipment allocation and usage.
Support efficient use of health and social care resources by ensuring timely coordination of services.
Handle and manage supplies and equipment in accordance with organisational procedures.
Contribute to monitoring resource utilisation through data collection and reporting activities.
7. Leadership and management:
Coordinate activities across multidisciplinary teams to support effective integrated care delivery.
Provide information, advice and guidance to colleagues regarding processes, pathways and available services.
Support new team members in understanding administrative processes and information systems as required .
Act as a key administrative resource for the Integrated Neighbourhood Team.
Promote collaborative working relationships across health, social care and voluntary sector organisations.
Contribute to service development through sharing knowledge, identifying improvements and supporting implementation of agreed changes.
This involves working with all health and social care professionals, as well as statutory/non statutory agencies, to provide a seamless, integrated service to our service users . You will be required to work flexibly between the acute and community sites as the role dictates; own transport will be needed for this.
